Uni-Knees in the Outpatient Setting

Performance, Efficiency, Achievement, Knowledge
Uni-Knees in the Outpatient Setting:
Is this the right fit for your ASC?
The 7th Annual Orthopedics, Pain Management
and Spine Driven ASC Conference
June 11 – 13, 2009
Presenters: Sarah Martin, RN, BSN, CASC, Blaine Farless, M.D., James McGehee, RN
Performance, Efficiency, Achievement, Knowledge
Outpatient Unicompartmental Knee Replacement
Part I
Presenter:
Blaine Farless, M.D.
Founding Partner and Orthopedic Surgeon
Cleburne Surgical Center
Cleburne, Texas
Advantages
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Reduced Cost
Patient Satisfaction
Doctor Satisfaction
Theoretical Lower Infection Rate Reduction
You don’t want this
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Who is a Candidate?
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Medial Joint Arthritis
Young
Healthy
Close to ideal Body Weight
Involved in some type of physical activity
Does not take narcotics
Make the Diagnosis
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Make the Diagnosis Before Surgery
1. Previous Arthroscopy “Best”
2. MRI Scan that show NO lateral disease
3. Bone Scan increase up take medial Compartment
4. History
5. Plain standing X-rays
6. Physical Exam
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Consider Arthroscopy
  If unsure of the diagnosis before making the arthrotomy, Do a
Diagnostic Arthroscopy…… If there is Lateral Joint Disease
not a candidate for partial knee replacement.
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Not a Candidate
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Age is Relative
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Increased sensitivity to medication
Increased risk of cardiovascular event
Older people do well with total knees
Not a Medicare approved out patient Procedure
Healthy
Avoid an unplanned hospital admission
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Diabetic
CHF
Previous MI
History of Blood Clots difficult anesthesia
Activity - Couch potatoes need not apply
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Obesity
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More difficult procedure
More difficult anesthesia
Increased infection rate
Increased risk of wound Problems
Increased risk of DVT
More work for family
Narcotics
  The biggest challenge to outpatient surgery is pain control!
  Do not start out in the narcotic hole
  An occasional Vicoden or Darvocet is ok but be careful with
patients on pain medications
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The New Arthritis Medication?
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PRE-OP Planning
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Hibiclens shower
Home Health
CPM
Crutches or Walker
Post-op Prescriptions
Insurance Pre-certification
This is an expensive procedure…
you don’t want an expensive surprise
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Not Medicare Approved
Blue Cross of Texas Does not Cover
Make sure Patient understands their Responsibility
Anesthesia Is the Key
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Regional Block (Femoral)
No real advantage to spinal in the ASC
Local anesthesia (Posterior Capsule)
Pre-op Toradol
Pre-op Oxycotin 20mg
Post – OP Scripts
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Vicoden and Darvacet
Flexeril or Xanax
Toradol
Phenergan
Coumadin 2mg
Consider…
Helps to have a pain doctor partner
  Pain Patches
  Triplicate analgesics
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Antibiotics
  2 Gram Ancef 30 minutes prior
  2 Gram Ancef on discharge
  Consider 1 gram Vancomycin pre and post op
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Home Health
  Home health and a cpm machine are good ideas with a pre-op
and night of surgery visit.
  Interesting enough it is difficult to get this service with nonMedicare patients and is not an absolute necessity
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Equipment
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Power tools
Larger Retractors
Cement Mixing
C-Arm
Procedure
  Do early in the day
  Takes approximately 90 minutes
  Inject local in the Posterior Compartment before cementing
implants
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Recovery Room
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Ice
Antibiotics
Pain meds (Oxycontin)
Crutches or Walker
Follow Up
  Home health is a plus but not necessary
  CPM helps stiffness and in most patients reduce pain and
improve function
  Explain to patient and family to try and stay ahead of the pain
  Follow up in clinic in 2-3 days
  Prefer out patient therapy
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Results
  Crutches 2 weeks
  Most activities 4 weeks
  Athletics gradual return over about 12 weeks
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Hurdles
  Making the diagnosis; although I think outpatient total knee
replacement is a viable cost
  Insurance Approval….
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Comment
  Outpatient Joint Replacement is s viable cost effective
alternative to hospital based surgery
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Performance, Efficiency, Achievement, Knowledge
Outpatient Unicompartmental Knee Replacement
Part II
Presenters:
Presenters: Sarah Martin, RN, BSN, CASC – RVP of Operations – Meridian Surgical Partners
James McGehee, RN – Administrator – Cleburne Surgical Center
Equipment Needs
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Inventory current equipment
Identify outstanding items needed
Obtain quotes for feasibility review
Ask sales reps to assist with acquiring equipment
Physician Recruitment
Physician Criteria:
  Seek an existing physician partner or utilizer currently performing these cases
at the hospital
  Physician should have good judgment regarding patient selection
  If recruiting a physician, do your homework
•  Identify a physician with a good reputation
•  Consult with sales reps and clinical staff as needed
  Identify physician who can perform the procedure in under 1 ½ hours
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Case Costing
  Get physician preference card and review with physician
  Determine supplies needed
  Cost of supplies
  Cost of implants
  Determine supply cost per case
  Determine salary cost per case
  Determine overhead/fixed costs per case
Other questions to ask:
  What are the margins for performing these cases at your ASC?
  Are there some payors that should not be performed in your ASC?
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Reimbursement
  Check payor reimbursement environment
  Determine cost of case vs. reimbursement
  Estimate monthly case volume
Questions to ask
  How many of procedures per month must be performed to be profitable?
  Can you utilize third party insurance billing for the implants?
  Analyze managed care contracts to determine whether a percentage of billed
charges or grouper arrangement will net the most dollars
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Anesthesia Considerations
  Consult with your anesthesia provider in the care plan
  Anesthesia provider should have excellent regional block skills
  Have supplies to perform a long-term regional block (consider a femoral
catheter)
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PeriOperative Considerations
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Have OR team view physician performing a Uni-knee
Perform a complete review with Staff for entire PeriOperative process
PACU considerations:
Ice Machines
CPM
Post op instructions
Performance, Efficiency, Achievement, Knowledge
Questions???
Contact Information
Sarah Martin, RN, BS, CASC (RVP of Operations)
Meridian Surgical Partners
615-346-4136
smartin@meridiansurg.com
James McGehee, RN (Administrator)
Cleburne Surgical Center
817-645-0811
jmcgehee@cleburnesurgical.com
Blaine Farless, MD (Orthopedic Surgeon)
Cleburne Surgical Center
817-556-3212
blfarless@msn.com
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